Fresh Whole Blood Collection and Transfusion at Point of Injury, Prolonged Permissive Hypotension, and Intermittent REBOA: Extreme Measures Led to Survival in a Severely Injured Soldier-A Case Report.

We present the case of a severely injured Special Operations Servicemember whose care was remarkable for three unique interventions: the first use of a walking blood bank performed at the point of injury, prolonged permissive hypotension, and intermittent resuscitative endovascular balloon occlusion of the aorta (REBOA).

A Collaborative To Evaluate And Improve The Quality Of Surgical Care Delivered By The Military Health System.

In an effort to improve surgical quality and reduce clinical variability, the Military Health System (MHS) expanded its participation in the National Surgical Quality Improvement Program to all military hospitals beginning in 2015. This expansion and a partnership with the American College of Surgeons laid the foundation for a surgical quality collaborative in the MHS. We review the history of the program in the MHS and the activities that have contributed to developing the collaborative. We also report promising trends in surgical outcomes at hospitals that were already participating in the program in 2014, when a critical MHS review identified areas for improvement in surgical care. We conclude with a discussion of possible lessons for other health systems and challenges ahead for the MHS, now that full enrollment in the program has been completed.

Early management of pediatric vascular injuries through humanitarian surgical care during U.S. military operations.

BACKGROUND: The objective of this report is to describe our experience of pediatric vascular injuries in a U.S. military combat support hospital in Baghdad, Iraq. A retrospective study was designed using Joint Theater Trauma Registry (JTTR) records in order to evaluate the pediatric (age <18 years) population presenting with vascular trauma to a combat hospital in Baghdad, Iraq between April 2006 and August 2008. Demographic data comprised casualty, age, gender, and mechanism of injury. Physiologic data included presenting vital signs (rectal temperature, blood pressure, and heart rate), arterial pH, base deficit, hemoglobin (g/dL), and international normalized ratio. RESULTS: Twenty-five children, median age 14 years (range, 5-17 years), median weight 48 kg (range, 15-80 kg) sustained 18 (72%) blast and 7 (28%) gunshot wounds. The mean Injury Severity Score was 25 ± 16.2. The median operative time for the vascular repairs was 189 minutes (range, 41-505 minutes). Patients were tachycardic (mean ± standard deviation, 136 ± 29 bpm), hypotensive (109/63 ± 29/19 mm Hg), and acidemic (pH 7.26 ± 0.07; BD -5.57 ± 5.1 mEq/L) on arrival to the emergency department and were physiologically improved upon admission to the intensive care unit 3 hours later. Repair techniques were ligation (14; 39%), saphenous graft (11; 31%), lateral suture (7; 19%), end anastomosis (2; 5%), patch (1; 3%), and thrombectomy (1; 3%). Twenty-four hour mean transfusion requirements included crystalloid 102 mL/kg (range, 19-253), transfused blood 47 mL/kg (range, 0-119), fresh frozen plasma 14 mL/kg (range, 0-68), and apheresis platelets (1.2 ± 3.68 units). Over a follow-up of 22 ± 5.5 days, the amputation-free survival was 80%. CONCLUSIONS: This is the largest reported wartime series to demonstrate in children that damage control resuscitation despite high injury severity permits simultaneous limb salvage.

Epigenetic silencing of beta-spectrin, a TGF-beta signaling/scaffolding protein in a human cancer stem cell disorder: Beckwith-Wiedemann syndrome.

Hereditary cancer syndromes provide powerful insights into dysfunctional signaling pathways that lead to sporadic cancers. Beckwith-Wiedemann syndrome (BWS) is a hereditary human cancer stem cell syndrome currently linked to deregulated imprinting at chromosome 11p15 and uniparental disomy. However, causal molecular defects and genetic models have remained elusive to date in the majority of cases. The non-pleckstrin homology domain ß-spectrin (ß2SP) (the official name for human is Spectrin, beta, nonerythrocytic 1 (SPTBN1), isoform 2; the official name for mouse is Spectrin beta 2 (Spnb2), isoform 2), a scaffolding protein, functions as a potent TGF-ß signaling member adaptor in tumor suppression and development. Yet, the role of the ß2SP in human tumor syndromes remains unclear. Here, we report that ß2SP(+/-) mice are born with many phenotypic characteristics observed in BWS patients, suggesting that ß2SP mutant mice phenocopy BWS, and ß2SP loss could be one of the mechanisms associated with BWS. Our results also suggest that epigenetic silencing of ß2SP is a new potential causal factor in human BWS patients. Furthermore, ß2SP(+/-) mice provide an important animal model for BWS, as well as sporadic cancers associated with it, including lethal gastrointestinal and pancreatic cancer. Thus, these studies could lead to further insight into defects generated by dysfunctional stem cells and identification of new treatment strategies and functional markers for the early detection of these lethal cancers that otherwise cannot be detected at an early stage.

Quality of life of patients with Takayasu's arteritis.

OBJECTIVE: Takayasu's arteritis (TA) is a chronic immune vasculitis that causes inflammation of the aorta and its branches and is clinically characterized by exacerbations and remissions. This study examined the quality of life (QoL) of patients with TA using the Medical Outcomes Study Short Form 36 (SF-36) Health Survey, a validated health related QoL questionnaire. METHODS: Questionnaires that included the SF-36 and demographic related variables were mailed to 392 patients enrolled in the Takayasu's Arteritis Research Association. Raw SF-36 scores, as well as Physical Health Summary (PHS) and Mental Health Summary (MHS) scores, were calculated according to standard protocols. Data were analyzed for predictors of superior QoL using univariate and stepwise logistic regression analysis. SF-36 scores were also compared with those of other chronic diseases associated with peripheral vascular disease (PVD) published in the literature. Results are reported as mean +/- standard error of the mean. RESULTS: A total of 158 patients (144 women, 14 men) with average age of 42.2 +/- 1.1 years responded to the questionnaire. Mean onset of symptoms occurred at 30.5 +/- 1.2 years, with a mean age at diagnosis of 34.7 +/- 1.2, and a median of four doctors were seen before diagnosis. The group underwent 299 TA-related surgical procedures (1.9 +/- 0.3), including coronary (38%), carotid (35%), upper extremity (30%), and lower extremity (26%) revascularization. PHS and MHS summary scores (39.2 +/- 1.0 and 44.5 +/- 1.0, respectively) were worse than mean scores for an age-matched healthy population as well as nationally reported scores for diabetes mellitus, hypertension, and coronary artery disease (all P < .0001). Multivariate predictors of better physical QoL were younger age (P = .003) and remission of the disease (P = .0002). The use of immunomodulating medications was associated with inferior physical QoL (P = .02). The sole predictor of better mental QoL was remission of disease (P = .002). CONCLUSION: TA is a rare disease with profound consequences on QoL. Scores for physical and mental health are worse compared with many other chronic diseases associated with PVD. Superior physical QoL is seen in younger patients, whereas inferior physical QoL is encountered in those who take immunomodulating medications. Because the only factor to influence positively both physical and mental QoL is disease remission, every effort should be directed to attenuate disease activity.

Learning and memory is preserved after induced asanguineous hyperkalemic hypothermic arrest in a swine model of traumatic exsanguination.

BACKGROUND: Induced asanguineous hypothermic metabolic arrest (suspended animation) could provide valuable time to repair major vascular injuries if safely induced in patients with trauma. We report a novel method of doing this in a swine model of uncontrolled lethal hemorrhage (ULH) that resulted in preservation of learning ability and memory. METHODS: Yorkshire swine (100 to 125 lb) underwent ULH before rapid intra-aortic infusion of a hypothermic (4 degrees C), hyperkalemic (70 mEq/L) organ preservation solution by a left thoracotomy. Cooling continued until core temperature reached 10 degrees C, and this was maintained for 60 minutes using low-flow cardiopulmonary bypass. Vascular injuries were repaired during this state of suspended animation, which was then reversed, and the animals were observed for 6 weeks. Cognitive functions were tested by training animals to retrieve food from color-coded boxes. Postoperatively, the ability to remember this task and a 75-point objective neurologic scale were used to test neurologic function. In experiment I, ULH was caused by lacerating thoracic aorta (n = 9). Five preoperatively untrained animals were trained to perform the task and compared with control animals (n = 15), and 4 preoperatively trained animals were tested for memory retention postoperatively. In experiment II, ULH was induced by creating an iliac artery and vein injury (n = 15). Animals were kept in shock for 15, 30, and 60 minutes before the induction of hypothermia. RESULTS: In experiment I, surviving animals (7/9) were neurologically intact, and their capacity to learn new skills was no different than for control animals. All pretrained animals demonstrated complete memory retention. In experiment II, survival with 15, 30, and 60 minutes of shock were 80%, 60%, and 80%, respectively. All animals (except 1) in the 60-minute group were neurologically intact and displayed normal learning capacity. CONCLUSIONS: Induction of hypothermic metabolic arrest (by thoracotomy) for repair of complex traumatic injuries is feasible with preservation of normal neurologic function, even after extended periods of shock from an intra-abdominal source of uncontrolled hemorrhage.